What is the first line treatment for a patient experiencing wheezing, possibly with a history of asthma or Chronic Obstructive Pulmonary Disease (COPD)?

First-Line Treatment for Wheezing

Immediately administer nebulized short-acting beta-agonist (salbutamol 2.5-5 mg or terbutaline 5-10 mg) to any patient presenting with wheezing, and add ipratropium bromide 500 μg if symptoms are severe or response is poor. 1

Initial Bronchodilator Therapy

Beta-Agonist Administration

• Nebulized salbutamol 2.5-5 mg or terbutaline 5-10 mg should be given immediately via nebulizer driven by oxygen (in acute asthma) or air (in COPD or stable patients) at 6-8 L/min flow rate 2
• Treatment produces bronchodilation within minutes, peaking at 15-30 minutes, with effects lasting 4-5 hours 2
• The inhaled route results in fewer adverse effects compared to oral or parenteral administration 2

When to Add Anticholinergic Therapy

• Add ipratropium bromide 500 μg to the beta-agonist for acute asthma with severe symptoms or poor initial response, repeating every 4-6 hours 2, 1
• For acute COPD exacerbations, beta-agonist monotherapy is typically sufficient, as no additional benefit has been demonstrated when anticholinergics are added in this specific context 2
• However, combined nebulized treatment (beta-agonist + ipratropium 250-500 μg) should be considered in severe COPD cases or with poor response 1

Severity Assessment Guides Treatment Intensity

Severe Asthma Features Requiring Aggressive Treatment

• Inability to complete sentences in one breath, respiratory rate ≥25/min, heart rate ≥110/min, or peak expiratory flow ≤50% predicted 1
• These patients require immediate nebulized therapy with combined beta-agonist and ipratropium 1

Life-Threatening Features

• Peak flow <33% predicted, silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, exhaustion, confusion, or coma 1
• These patients need continuous nebulized therapy until stable, with senior clinician review and consideration of noninvasive ventilation or intensive care 2

Treatment Frequency and Duration

• Repeat nebulized treatment within a few minutes if suboptimal response to first dose, or administer continuous nebulized therapy until the patient stabilizes 2
• For good responders, repeat treatment at 4-6 hour intervals until recovery occurs 2
• Treatment duration should be 10 minutes for bronchodilators to ensure adequate drug delivery 2

Critical Technical Considerations

Gas Source Selection

• Use oxygen to drive nebulizers in acute severe asthma patients due to hypoxia 2
• Use air-driven nebulizers in COPD patients to avoid increasing CO2 retention, with supplemental low-flow oxygen via nasal cannulae if needed 2
• Shorter nebulization periods (<10 minutes) may make CO2 retention less of an issue with modern nebulizer systems 2

Delivery Method

• Mouthpieces may theoretically be better by avoiding nasal deposition, though clinical studies show no advantage over face masks in stable patients 2
• Breathless patients may prefer face masks, which are appropriate as these patients typically mouth-breathe 2
• Use mouthpieces for anticholinergics to avoid ocular complications like glaucoma exacerbation 2

Adjunctive Therapy

Corticosteroids

• Add oral corticosteroids (30 mg prednisolone daily) early in moderate-severe exacerbations, as they improve lung function, shorten recovery time, and reduce hospitalization duration 1

Antibiotics

• Indicated when sputum becomes purulent, with a 7-14 day course of amoxicillin, tetracycline derivatives, or amoxicillin/clavulanic acid 2, 1
• Common organisms include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2

Common Pitfalls to Avoid

• Never substitute oral bronchodilators for nebulized therapy in acute presentations, as nebulized delivery provides superior immediate bronchodilation 1
• Do not routinely use oxygen to drive nebulizers in COPD patients due to CO2 retention risk 2
• Ensure patients rinse their mouth after nebulizing steroids to prevent oral thrush 2
• Lack of response to repeated nebulized therapy indicates need for senior clinician review and possible escalation to noninvasive ventilation or intensive care 2

Transition to Maintenance Therapy

• Switch to hand-held inhalers as soon as the patient's condition stabilizes, as this permits earlier discharge 2
• Change to hand-held reliever/preventer medication 24 hours before discontinuing frequent nebulizations 1
• Ensure proper inhaler technique is demonstrated before discharge 1
• For mild exacerbations, hand-held inhaler with salbutamol 200-400 μg or terbutaline 500-1000 μg may be sufficient 1